Acute Stress Disorder: Conceptual Issues and Treatment Outcomes

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Cognitive and Behavioral Practice 19 (2012) 437-450 www.elsevier.com/locate/cabp

Acute Stress Disorder: Conceptual Issues and Treatment Outcomes Ellen M. Koucky, Tara E. Galovski, University of Missouri–St. Louis Reginald D.V. Nixon, Flinders University Acute stress disorder (ASD) was included as a diagnosis to the 4th edition of the Diagnostic and Statistical Manual (American Psychiatric Association, 1994) as a way of describing pathological reactions in the first month following a trauma. Since that time, ASD has been the focus of some controversy, particularly regarding the theoretical basis and practical utility of the disorder. Despite this controversy, ASD has demonstrated usefulness in identifying individuals experiencing a high level of distress in the acute aftermath of a trauma as well as those at risk for developing posttraumatic stress disorder (PTSD). This paper reviews the clinical application of ASD, the current controversy surrounding its conceptual basis, and then discusses the dilemmas regarding this diagnosis that might occur in clinical practice. A review of the randomized control trial treatment outcome literature for ASD is also included in an effort to assist clinicians selecting interventions for clients recently exposed to traumatic events. Throughout this paper, the relationship between research and applied clinical practice is highlighted.

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exposure to a traumatic stressor is a relatively common human experience, but differences exist in reactions to the event and the longitudinal course of symptoms. Data from the National Comorbidity Survey indicates that 61% of men and 51% of women reported exposure to at least one traumatic event during the course of their lifetime (N = 5,877; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). Experiencing some degree of transient psychological distress in the weeks following a traumatic experience is also common (Bryant, 2003c; Foa & Riggs, 1995) and may actually be considered normative. The rate of individuals initially meeting criteria for posttraumatic stress disorder (PTSD) shortly after a traumatic event varies by type of event and significantly decreases in subsequent weeks (Blanchard et al., 1996; Rothbaum, Foa, Riggs, Murdock, & Walsh, 1992), most likely due to resiliency or simple recovery from symptoms without clinical intervention (Bonanno, 2004). However, reactions are labeled as pathological and may require clinical attention when their intensity or duration reaches a certain severity level currently demarcated by the diagnostic criteria for acute stress disorder (ASD) and IFETIME

Keywords: acute stress disorder; treatment; trauma; cognitive behavioral therapy 1077-7229/11/437-450$1.00/0 © 2011 Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd. All rights reserved.

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PTSD (American Psychiatric Association, 2000). Adjustment disorder is another clinical diagnosis that may be used to describe clinically significant distress following exposure to trauma, but is not necessarily preceded by trauma exposure. In these circumstances, the diagnostic criteria for these disorders distinguish a boundary between normative and pathological reactions following a trauma and provide guidance in deciding when clinical intervention is warranted. Although these three diagnoses all represent reactions to trauma, this review focuses specifically on the acute reactions to a traumatic event consistent with a diagnosis of ASD. This article will specifically review the efficacy of treatments for this disorder with the overall goal of offering guidance to clinicians in determining the course of treatment for this clinical presentation. Prior to this review, the etiology of ASD and its inception into the DSM-IV requires some discussion. Criticisms about ASD have been voiced that question the additive benefit and clinical utility for creating another disorder that so closely resembles PTSD (e.g. Bryant, 2003a, 2003b). Some clinicians and researchers also disagree with the diagnostic emphasis placed on dissociative symptoms in the criteria for ASD (Bryant & Harvey, 1997; McNally, Bryant, & Ehlers, 2003). Despite these criticisms, ASD has proven useful as a way of describing acute pathological reactions following a trauma. Additionally, ASD can predict those at risk for developing chronic PTSD. These qualities highlight the diagnosis of ASD as a way to identify individuals who may benefit from more immediate interventions as opposed to individuals whose symptoms

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may naturally remit with time. The treatment of ASD has shown promising evidence both in the remission of primary symptoms and in the prevention of PTSD (e.g., Bryant et al., 2006). Conclusions regarding the concept of ASD and the current status of the treatment outcome literature have broad implications for clinicians in practice, given the prevalence of trauma exposure and the likelihood of working with this client population.

Description and Prevalence of ASD ASD was first utilized as a diagnosis in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994) to describe posttraumatic reactions. Diagnostic criteria specify that ASD may develop after an individual has been exposed to a threatening event that elicits a response of fear, helplessness, or horror (Criterion A). The presence of dissociative symptoms (Criterion B), reexperiencing symptoms (Criterion C), marked avoidance of the traumatic stimuli (Criterion D), and marked symptoms of hyperarousal (Criterion E) are also required. Additionally, the disturbance must persist for a time frame between 2 days to 4 weeks after the onset of the traumatic event and cause clinically significant distress (Criterion F and G). The primary difference between ASD and PTSD is the specified time frame when the disorder may be diagnosed. PTSD must be diagnosed at least 1 month following the trauma, while ASD must be diagnosed within 2 days to 4 weeks after the trauma. However, it is important to mention that certain treatment guidelines suggest that active interventions for ASD should be considered only after the posttrauma 2-week mark has elapsed (Australian Centre for Posttraumatic Mental Health, 2007). The rationale for this treatment directive is to allow time for the natural recovery process to begin and to monitor individuals beginning to show psychopathology compared to those exhibiting resiliency. Additionally, the high level of distress exhibited by individuals in the hours and days following an acute trauma may prevent implementation or limit the effectiveness of therapeutic interventions (American Psychiatric Association, 2004). An additional distinction between ASD and PTSD is the required presence of dissociative symptoms in the ASD diagnosis. Although dissociative symptoms may be present with both disorders, ASD specifically requires an individual to have at least three of five specific symptoms of dissociation, including: a subjective sense of numbing or detachment, a reduction in awareness of surroundings, derealization, depersonalization, and dissociative amnesia. The prevalence rates for ASD appear to vary widely from 7% to 33% based on the type of precipitating trauma and differences in assessment methods (see Bryant,

2003a, 2003c, for review of prevalence rates of ASD based on trauma type), with trauma of an interpersonal nature generally producing higher rates of acute distress. Clinicians should be mindful to assess for symptoms of ASD when clients present for treatment after recently experiencing a trauma such as motor vehicle accident, interpersonal assault, combat exposure, or natural disaster. Revisions to the diagnostic criteria scheduled to be published in DSM-5 are still underway and require extensive validation through the field trial process, but initial reports suggest that important changes may be in store for ASD. Specifically, the proposed revisions still include a listing of dissociative symptoms (derealization, depersonalization, dissociative amnesia), but no longer stipulate that a specific number of dissociative symptoms must be present to meet criteria for the disorder (American Psychiatric Association, 2010). This change still acknowledges the relevance of dissociative symptoms to ASD, but deemphasizes these symptoms as a major focus of the disorder. Additionally, the first point at which ASD can be diagnosed may be changed from 2 to 3 days posttrauma. Although this change may not appear substantial, it reflects an effort to prevent overpathologizing normative distress responses in the immediate aftermath of a traumatic event (Blanchard et al., 1996; Rothbaum et al., 1992).

Purpose and Predictive Validity of ASD Prospective research monitoring diagnostic status for PTSD after exposure to a trauma has shown that symptoms dramatically decrease over time for most individuals. A study by Rothbaum et al. (1992) evaluating a sample of 95 female rape victims discovered that 94% of the sample met criteria for PTSD in the week following the traumatic event (excluding the necessary 1-month symptom duration criteria). This number decreased to 65% at the 4-week assessment point and 47% at the 12-week assessment point without any intervention. Additional prospective studies also show dramatic rates of natural recovery. At baseline assessment, over 70% of women and 50% of men who experienced a nonsexual assault demonstrated PTSD symptoms, which decreased to 21% of women and 0% of men at 3-month follow-up assessment (N = 84; Riggs, Rothbaum, & Foa, 1995). In a sample of female rape and physical assault victims (N = 122), 81% of sexual assault victims and 63% of physical assault victims met criteria for PTSD in the first month following exposure to the traumatic event (minus the Criterion E time requirement). Participants were reassessed at the 3-month mark and rates of PTSD decreased to 53% of sexual assault survivors and 31% of physical assault survivors (Gutner, Rizvi, Monson, & Resick, 2006). This prospective data collectively suggests

ASD Treatment Outcomes that most individuals exposed to a traumatic event will develop significant distress immediately after the trauma. However, many of these survivors will recover independently of any psychiatric or psychological intervention. Thus the challenge becomes identifying those who will not recover and attempting to provide care early enough to afford relief and prevent the development of chronic distress. In light of the growing understanding of normative reactions to trauma, the diagnostic criteria for PTSD were changed in DSM-III-R (American Psychiatric Association, 1987) to include a minimum duration requirement that symptoms persist for at least 1 month. This served the function of increasing specificity of the disorder and avoiding Type I (false positive) errors in diagnosis. After these modifications to the criteria for PTSD, the only diagnosis that could be used to describe psychopathology within the 1-month period immediately following the trauma was adjustment disorder (Marshall, Spitzer & Liebowitz, 1999), which fails to describe the full range and clinical impact of posttraumatic symptoms. The focus of the general trauma literature on longer-term PTSD had potentially neglected the importance of clinically significant distress caused by acute posttraumatic reactions (Lynn & Cardeña, 2007). ASD was developed to fill the “nosologic gap” for clinically significant levels of psychopathology present in the month following a trauma before a diagnosis of PTSD could be rendered (Harvey & Bryant, 2002). Therefore, clinicians may use the criteria for ASD as a guide toward differentiating normative from pathological responses in the acute aftermath of trauma. A significant amount of diagnostic similarity exists between ASD and PTSD. These diagnoses have a temporal relationship such that the diagnosis of ASD may (but not necessarily) precede a diagnosis of PTSD. In light of these circumstances, prospective studies have been designed to increase understanding of the trajectory of posttraumatic symptomatology and clarify the relationship between ASD and PTSD (see Bryant, 2011, and McNally et al., 2003, for full review). The range of results (discussed in more detail below) obtained by these prospective studies suggest that although trends may be identified, some ambiguity still exists in terms of the clinical course of posttraumatic symptoms within the context of ASD and PTSD. Some research has demonstrated that the diagnosis of ASD does not adequately predict cases that go on to develop PTSD. A study by Creamer, O'Donnell, and Pattison (2004) examined a hospital sample (N = 597) that had experienced some type of severe physical injury, most commonly as a result of motor vehicle accidents. Results showed that only the reexperiencing and hyperarousal clusters of ASD showed significant utility in predicting PTSD diagnostic status at three month and 12-month

follow-up. Some limitations to this study might reduce the applicability of the results as only 1% of the sample met criteria for ASD at initial assessment, thus the total ASD sample used to examine the predictive validity of ASD for PTSD at follow-up was very small. Additionally, the study was conservative in its assessment of dissociative symptoms, by taking particular care to ascertain whether symptoms were better attributed to other causes (e.g., physical injuries, medication, and hospital environment). For example, due to the high prevalence of head injury in their motor vehicle accident sample, the authors excluded the symptom of psychogenic amnesia for all participants. The sample was also assessed for ASD symptoms while still receiving treatment in the hospital. Such circumstances may have affected acute posttraumatic symptom presentation due to the level of care and social support that individuals would be receiving as well as the lack of trauma reminders they may encounter in that setting. Other prospective studies have shown that ASD demonstrates significant predictive validity in identifying cases that go on to develop PTSD. In a sample of motor vehicle accident survivors (n = 71), Harvey and Bryant (1998) concluded that 78% of ASD positive participants met criteria for PTSD at 6-month follow-up. The same study group evaluated a similar motor vehicle accident sample (n = 50) and found that 80% of cases that met initial criteria for ASD went on to develop PTSD at 2-year follow-up (Harvey & Bryant, 2000). Additionally, Brewin, Andrews, Rose, and Kirk (1999) studied a sample of violent interpersonal assault survivors (n = 138) and found that 83% of cases initially positive for ASD later met criteria for a diagnosis of PTSD. In conclusion, the majority of prospective studies on the relationship between ASD and PTSD appear to suggest that a substantial majority of ASD trauma survivors will go on to develop PTSD in the absence of treatment. Specific ASD symptoms, including acute numbing, depersonalization, and reexperiencing, have also received noteworthy attention in terms of their individual ability to predict a future diagnosis of PTSD (Harvey & Bryant, 1998). The dissociative symptoms emphasized in ASD have been shown to play a role in the immediate as well as long-term stress responses to traumatic events (Butler, Duran, Jasiukaitis, Koopman, & Spiegel, 1996; Foa & Riggs, 1995; Koopman, 2000). Early manifestation of these dissociative symptoms indicates a certain level of severity in the acute trauma response. In addition, the presence of dissociation presents significant implications for the later development, severity, and chronicity of PTSD (Simeon & Guralnik, 2000). The overall consensus from the prospective study of ASD research seems to conclude that ASD has some positive predictive power toward identifying cases that will go on to develop PTSD.

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However, the focus which it places on dissociative symptoms may create a lack of sensitivity in detecting some forms of significant posttraumatic psychopathology that can progress into PTSD. Thus, from a clinical standpoint, the presence of specific symptoms (particularly dissociation) in the acute aftermath of trauma may be a good clinical indicator of significant distress warranting clinical intervention. That being said, depending on the presence of dissociation alone as determining the need for treatment may be a disservice to a minority of clients whose clinical presentation does not include such symptoms. Identifying cases that are at risk for developing longterm psychopathology and implementing early interventions following a trauma clearly has its benefits (Bisson, 2008; Ehlers et al., 2003; Foa, Hearst-Ikeda, & Perry, 1995; Resnick et al., 2007). However, the early intervention literature has seen varied rates of success and even some reports of harm (see Litz, Gray, Bryant, & Adler, 2002, for full review). Research has shown that the majority of trauma survivors recover from traumatic exposure without clinical intervention and without developing psychopathology. This point makes it difficult to rationalize interrupting the successful normal recovery process. Data suggest that interventions (with careful consideration toward modality and duration) should be provided to individuals most at risk for developing chronic psychopathology. The diagnosis of ASD serves an important function given its ability to identify individuals with acute posttraumatic symptoms that exceed the normative response and are most in need of services to prevent chronic impairment.

ASD Controversy ASD has experienced a certain amount of criticism challenging its theoretical basis and clinical utility as a descriptor of psychopathological reactions to trauma. Due to the similarity between the causative factors, clinical presentation, and diagnostic criteria for ASD and PTSD, some make the argument that a continuous clinical phenomenon (posttraumatic reaction) has been needlessly dichotomized into two separate diagnoses (Marshall et al., 1999). The demonstrated predictive ability of ASD to identify later PTSD caseness previously reviewed might reflect a continuation of the same clinical phenomenon rather than two distinct disorders. Thus, the suggestion has been made to reconsider the diagnostic criteria for PTSD so that it is more inclusive toward the entire spectrum of posttraumatic responses, including those that may be acute (Butler, 2000; Simeon & Guralnik, 2000). Again, it is questionable whether a diagnosis should exist as an independent entity if its primary function is to predict the onset of another disorder, particularly if it cannot do this with precise sensitivity and specificity. It is

worth noting that no other diagnostic classification in the DSM exists for this purpose. Taking a closer look at the definition for a mental disorder provided by the DSM reveals that even though ASD may be very highly related to PTSD, it does independently fit the criteria for a mental disorder. A portion of the definition states that mental disorders are “conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability” (DSM-IV-TR, p. xxxi). ASD certainly describes a “clinically significant behavioral or psychological syndrome” in a way that is unique from the diagnostic criteria for PTSD, given the focus on dissociative symptoms and the time frame that ASD encompasses. Therefore, despite significant overlap with PTSD, it appears that ASD does uniquely fit the criteria for the description of a mental disorder proposed by the DSM in ways that can be useful to clinical practice. An additional criticism of ASD includes the manner in which the diagnosis was first included in the DSM. Prior to the publication of DSM-IV, most diagnoses for inclusion in the manual were assessed based on literature reviews, data analyses and field trials. The purpose of the field trials was to compare diagnostic criteria between DSM-III, DSM-III-R, International Classification of Diseases (ICD)-10, and the proposed DSM-IV criteria sets. An additional goal was to provide reliability and validity data for the controversial and substantial revisions in DSM-IV (DSM-IV-TR; Widiger, Frances, Pincus, Davis, & First, 1991). The field trials conducted for DSM-IV were sponsored by the National Institute of Mental Health (NIMH), the National Institute of Drug Abuse (NIDA), and the National Institute on Alcohol Abuse and Alcoholism (NIAAA). Eleven diagnostic categories were examined in the trials, including PTSD, but ASD was not specifically subjected to this empirical rigor prior to inclusion in the final classification system (Bryant, 2003a, 2000; Frances, Davis, Kline, & Pincus et al., 1991) despite the fact that DSM-IV was the first manual that included ASD. Another area of criticism is the focus that ASD places on dissociative symptoms. Dissociative symptoms were included as part of the required criteria of ASD as a way of differentiating normative from pathological acute responses to a traumatic event (avoiding Type I errors), but some have concluded that this emphasis is unnecessary. Marshall et al. (1999) summarized this argument by stating, “acute stress disorder singles out one of several risk factors for PTSD—peritraumatic dissociation—and elevates it to the status of a core symptom of a new disorder” (p. 1679). Such a move may be redundant with PTSD and can overpathologize a transient posttraumatic reaction. In fact, this focus on dissociative symptoms may interfere with identification of some cases at risk for

ASD Treatment Outcomes developing chronic PTSD (essentially creating a Type II error). As a result, some individuals would not be provided crucial early intervention services as discussed above. In a prospective study by Harvey and Bryant (1998) examining the relationship between ASD and PTSD diagnoses in a motor vehicle accident sample (n = 71), 60% of subjects meeting subclinical criteria for ASD met criteria for PTSD at 6-month follow-up. The most common reason that these individuals did not meet initial criteria for ASD was an absence of dissociative symptoms. In other words, the dissociative cluster of symptoms unique to the ASD diagnosis was limiting accuracy in identification of trauma survivors that go on to develop PTSD. Some of the difficulty with using dissociative symptoms as part of the diagnostic criteria for ASD may be related to the way these particular symptoms are defined and measured. The DSM-IV criteria for ASD are rather unspecific regarding precisely when the reported dissociative symptoms are experienced, stating they may occur either during the distressing event or sometime after (American Psychiatric Association, 1994). However, research has indicated significant differences in the way that peritraumatic dissociation (i.e., dissociation that occurs at the time of the trauma) versus persistent dissociation can affect trauma symptoms. Specifically, persistent dissociation has been identified as a better predictor of PTSD status than peritraumatic dissociation (Briere, Scott, & Weathers, 2005). Some level of peritraumatic dissociation may be a fairly normative response to a traumatic event (or at least not predictive of significant posttraumatic distress). The diagnostic criteria for the other symptom clusters for ASD indicate that the symptom must be “marked and persistent,” but the description for dissociative symptoms is considerably less explicit, failing to specify a necessary level of severity for the symptom to count. Lastly, measurement of dissociative symptoms is often accomplished through self-report measures or checklists. These measures may be worded in such a way that fails to differentiate peritraumatic dissociation from normative forgetting or intentional avoidance of disclosure (Bryant, 2007). Such measures will also rely on retrospective accounts of peritraumatic dissociation, which may be inaccurate. Given the ambiguity surrounding dissociative symptoms, researchers and clinicians should seek to obtain more specific information to differentiate between peritraumatic and persistent dissociation and how these symptoms affect the individual. Specifically, clinicians may want to take into account not just the presence of dissociation (which may be relatively normative and even adaptive), but particularly query the severity, persistence, and related impairment of the dissociation. Another current issue regarding the diagnosis of ASD is the time frame of the disorder. The diagnostic criteria for

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ASD are in place to identify those experiencing a pathological level of distress in the first month following exposure to a traumatic event. Prospective studies suggest that a large proportion of individuals that initially meet criteria for ASD go on to meet criteria for PTSD after the 1month time frame has elapsed (see Bryant, 2011, for full review). However, the diagnostic and clinical implications for those that meet criteria for ASD and continue to experience distress past the 1-month time frame but do not meet formal criteria for PTSD is largely unclear. The potential for having trauma-exposed clients that fall between the diagnostic criteria for ASD and PTSD reiterates the need for clinical attention toward the diversity of symptomatic reactions that may occur following exposure to trauma. Clinical decision points around the issue will be further elaborated in the section discussing clinical dilemmas related to ASD. It has been proposed that developing alternative models for acute posttraumatic reactions that include peritraumatic factors (e.g., peritraumatic dissociation), acute symptoms (e.g., persistent dissociation), biological responses (e.g., physiological arousal, stress hormones), and cognitive styles (e.g., negative self-attributions) would be a more comprehensive avenue to identify those at risk for developing PTSD (Bryant, 2003c) while avoiding the stigma of a diagnosis such as ASD. However, no such approaches have been developed to date. Despite the argument surrounding the diagnosis of ASD, the prospective research demonstrates that ASD possesses utility in identifying cases that later go on to develop PTSD. Additionally, a more primary function of the diagnosis lies in its clinical usefulness in identifying individuals who are experiencing particularly significant symptoms in the acute aftermath of a trauma. Early detection of psychopathology can benefit trauma survivors who may then receive more immediate clinical intervention and potentially avoid the development of more chronic psychiatric conditions such as PTSD. Therefore, although ASD is highly related to PTSD and may predict its onset, the diagnosis of ASD is independent from PTSD based on the time frame of the disorder and the focus placed on dissociative symptoms. Given these distinguishing characteristics, it is beneficial for clinicians to place attention on becoming familiar with effective treatment options specifically developed for ASD.

Treatment of ASD Various forms of early intervention following exposure to trauma have been developed. As the primary focus of this review is to identify effective treatments for ASD specifically, inclusion criteria were used to classify studies that address this goal. The selection of treatment studies was limited to those including a sample meeting criteria

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for ASD at pretreatment. 1 It was also specified that study outcome variables include assessment of PTSD diagnosis and continuous measures of psychological symptoms at posttreatment and follow-up. Discussion of studies was limited to English-language journals or translations, studies pertaining to an adult sample, and studies conforming to the specified methodological standards of treatment outcome studies outlined by Foa and Meadows (1997). Some flexibility was allowed in terms of whether studies included specific computed ratings for interrater reliability and treatment adherence, though all included studies reported highly trained assessors and checks of treatment adherence. Cognitive behavioral therapy (CBT) has been utilized in the treatment of PTSD for decades, but the first study demonstrating the effective treatment of ASD with CBT was published in 1998 (Bryant, Harvey, Dang, Sackville, & Basten, 1998). Twenty-four individuals who experienced a motor vehicle accident or industrial accident were randomized to receive five sessions consisting of one and a half hours of either CBT treatment or supportive counseling (SC). The CBT treatment was comprised of education, progressive muscle relaxation, imaginal exposure, cognitive restructuring, and graded in-vivo exposure. The SC treatment focused on education about the trauma, problem-solving skills, and unconditional support. Significantly fewer participants in the CBT group met criteria for PTSD compared to the SC group at posttreatment (8% versus 83%) and 6-month follow-up (17% versus 67%). The CBT treatment group also reported less posttraumatic intrusion and avoidance symptoms and less state anxiety at posttreatment and follow-up, as well as less depression at follow-up. Bryant, Sackville, Dang, Moulds, and Guthrie (1999) sought to identify the “critical ingredients” of CBT for ASD that exert a therapeutic impact. They investigated a specific form of CBT (prolonged exposure; PE) that promotes the habituation of anxiety, examined the additive benefit of anxiety management training to PE, and compared these effects to an SC treatment group. All participants had experienced a motor vehicle accident or nonsexual assault and were randomized into a PE treatment group (n = 15), a PE plus anxiety management training group (n = 14), or an SC group (n = 16). The PE group was also supplemented with supportive counseling so that total treatment time in the PE and PE plus anxiety management groups was equivalent. Results of the study suggest greater efficacy for PE as significantly fewer subjects in the PE group (14%) and the PE plus anxiety management group (20%) met diagnostic 1

Two studies were listed with a sample that included a small number of subjects meeting criteria for subthreshold ASD, but this is discussed as a limitation in the methodology.

criteria for PTSD at 6-month follow-up, compared to the SC group (56%). Differences between the PE and the PE plus anxiety management group were not significant in terms of meeting diagnostic criteria for PTSD. Betweengroup comparisons of continuous outcome measures showed evidence for significantly higher scores on measures of posttraumatic symptoms for the SC group compared to the PE and PE plus anxiety management groups. These results indicate that PTSD caseness as well as the intensity of symptoms can be significantly reduced based on the provision of CBT to recent trauma survivors who meet criteria for ASD. Given the success of the PE treatment alone, the additive benefit of anxiety management training may be minimal. The inclusion of 7 subjects that did not meet full criteria for ASD (due to having two rather than three dissociative symptoms) could be considered a limitation for this study. The 11 subjects that dropped out of treatment (4 from PE plus anxiety management, 4 from PE, and 3 from the SC group) that reported significantly more severe ASD and higher levels of state anxiety should also be considered when interpreting the results. This may speak to the potential obstacles of engaging ASD-positive trauma survivors in treatment regardless of treatment type. A study by Bryant, Moulds, Guthrie, and Nixon (2003) investigated a novel application of CBT with a sample of 24 subjects who met criteria for ASD following either motor vehicle accidents or nonsexual assaults and sustained mild traumatic brain injuries. Subjects were randomly allocated into either a CBT or SC treatment condition 2 weeks after their trauma with treatment descriptions consistent with Bryant et al. (1998). The CBT group demonstrated significantly larger reductions in PTSD symptoms at posttreatment and 6-month follow-up and less anxiety symptoms at posttreatment. Additionally, significantly fewer subjects met criteria for PTSD in the CBT group (8%) than in the SC group (58%). However, it is important to mention that this percentage increased to 17% for the CBT group at the 6-month follow-up, suggesting the maintenance of treatment gains may need to be further investigated. In total, results of this study are consistent with prior findings indicating that CBT is effective at reducing posttraumatic symptoms and PTSD caseness for those with ASD. This study also demonstrates the flexibility of CBT for ASD being used with individuals who have experienced traumatic brain injuries and may be suffering from associated cognitive limitations. A concern raised by prior studies was the long-term maintenance of treatment gains for trauma survivors. To address this issue, a study by Bryant, Moulds, and Nixon (2003) reported on 4-year follow-up data of 41 subjects who received either CBT or SC in studies previously discussed by Bryant et al. (1998, 1999). Subjects in the CBT group reported significantly lower frequency and

ASD Treatment Outcomes intensity ratings for PTSD avoidance cluster symptoms, as well as significantly lower total symptom intensity scores. However, differences were nonsignificant in other PTSD subscales and overall frequency of PTSD symptoms. Statistical comparison based on diagnostic status for PTSD was limited due to sample size, but appeared to favor CBT (8%) over SC (25%). Interestingly, the number of SC treatment cases meeting diagnostic criteria for PTSD at the 6-month follow-up (approximately 66%) was notably reduced at the 4-year follow-up (25%). Results from this study again demonstrate the efficacy of CBT in treating ASD. The difference in PTSD diagnostic status between treatment conditions (CBT and SC) is notably smaller at 4-year follow-up compared to 6-month followup assessment results from other studies, but may be explained by a general reduction in PTSD caseness across all groups. Bryant, Moulds, Guthrie, and Nixon (2005) set out to investigate the additive benefit of hypnosis in the treatment of ASD. This treatment decision was made based on demonstrated higher rates of hypnotizability for those that meet criteria for ASD (Bryant, Guthrie, & Moulds, 2001) and research indicating that the use of hypnosis at the beginning of trauma-focused therapy may be helpful in reducing distress, hypervigilance, and fostering a sense of relaxation and control (Evans, 2003). With this premise in mind, 87 participants meeting criteria for ASD were randomized to either CBT treatment (consistent with Bryant et al., 1998, 1999; n = 24), CBT combined with hypnosis (n = 23), or an SC condition (n = 22). Sixty-nine subjects completed treatment and were retained at 6-month follow-up, yielding a dropout rate of 21% across the study. At the 6-month follow-up, 21% of the CBT condition and 22% of the CBT plus hypnosis condition met criteria for PTSD compared with 59% of the SC condition. Additionally, participants that completed treatment in the CBT and CBT plus hypnosis groups reported less PTSD symptoms at posttreatment and follow-up compared to the SC group. Contrary to the hypotheses proposed by the investigators, the CBThypnosis group did not evidence greater treatment gains than CBT alone. Of particular note in this study are the dropout rates for the CBT conditions that were approximately three times that of the SC group [dropout rates: CBT (27%), CBT-hypnosis (23%), SC (8%)]. These results are on par with prior studies with an ASD population (Bryant et al., 1998, 1999) but are nonetheless disappointing. Based on these dropout rates, incorporating hypnosis into CBT treatment for ASD may not have achieved its objective of reducing distress and fostering relaxation. Although dropout rates for the CBT conditions were higher than SC, this must be weighed against the significant benefit of the active CBT treatments in their ability to prevent the

onset of PTSD. Future studies may want to consider placing a focus on collecting data to specifically dismantle which aspects of ASD treatment and participant characteristics may be associated with dropout. A 3-year follow-up of the study completed by Bryant et al. (2005) was published in 2006 by Bryant et al. Results demonstrated that significantly fewer participants in the CBT (n = 2, 11%) and CBT plus hypnosis (n = 4, 22%) conditions met criteria for PTSD as compared to the SC group (n = 10, 62%) 3 years after treatment. Participants that received CBT or CBT plus hypnosis also reported significantly less reexperiencing and avoidance symptoms compared to those that received SC. These results reiterate that combining hypnosis with CBT treatment for ASD may not have added therapeutic benefit, but CBT shows consistent and long-standing effects in the treatment of ASD. In contrast to previous studies that primarily focused on utilizing general CBT treatment approaches or PE, Nixon (2007) used a modified version of cognitive processing therapy (CPT) to treat ASD. CPT emphasizes the identification of cognitions in both the interpretation of the event and in trauma-related themes (safety, trust, power, control, esteem, and intimacy), use of Socratic questioning to challenge maladaptive trauma-related thoughts, and assignment of a written account to encourage the expression of natural affect associated with the traumatic memory. In a pilot study, 20 interpersonal assault victims were randomized to receive either CPT or SC and treated with six 90-minute therapy sessions. Analyses demonstrated significant reductions in selfreported PTSD symptoms, depression, and traumarelated beliefs across treatment, but there were no significant differences between treatment conditions. In terms of treatment completer analyses, one of eight CPT participants (13%), and two of five SC participants (40%) met criteria for PTSD at posttreatment assessment, but the meaningfulness of these results is difficult to interpret based on sample size. Although the reported differences between the CPT and SC treatment conditions on continuous measures were less than might be expected, effect sizes for CPT were comparable to published study results for CBT suggesting that that the two treatments may be similarly effective at treating symptoms of ASD. Results should be replicated with larger sample sizes and the inclusion of a follow-up assessment to further assess the effectiveness of CPT for ASD. In 2008, Bryant et al. set out to replicate findings on the effectiveness of treating ASD with PE while determining whether the noteworthy dropout rate for PE in prior studies (e.g., Bryant et al., 1999) would be a consistent issue. Motor vehicle accident and nonsexual assault survivors that presented for treatment were randomized to receive PE (n = 30), cognitive restructuring (CR; n = 30),

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Koucky et al. or be placed in the waitlist control group (n = 30). Both active treatments consisted of five weekly 90-minute sessions. The PE condition included a similar course of treatment to that described in Bryant et al. The CR treatment condition included psychoeducation, identification and challenging of maladaptive thoughts through the use of Socratic questioning and evidence-based thinking, trauma-related discussion of harm, guilt, future ability to cope with stressors, and relapse prevention. Intent-to-treat analyses revealed that at 6-month followup, PE subjects were significantly less likely to meet diagnostic criteria for PTSD compared to those that received CR (37% vs. 63%; p = .05). The PE group also reported significantly less PTSD symptoms on continuous assessment measures compared to the CR group at followup. Of particular importance to this study is the fact that the PE group had a comparable dropout rate to CR, showing evidence that PE demonstrates tolerability as well as efficacy. Inclusion of a waitlist group in the design of this study was significantly useful in evaluating the natural remission of ASD symptoms compared to that caused by active treatment. At the posttreatment assessment time point, 15 waitlist participants (71%), 12 CR participants (52%) and 3 PE participants (12%) met criteria for PTSD. The PE group also demonstrated significantly lower scores than the waitlist group on measures of PTSD and depression, whereas the CR group did not differ from waitlist. Inclusion of the waitlist control group allows the researchers to test whether treatment efficacy greatly improves upon the natural remission of symptoms which may occur in time for some individuals (see Bryant, 2011, McNally et al., 2003, and Rothbaum et al., 1992 for further discussion). Such information is important to consider as treatments that cannot significantly improve upon the natural rate of remission may not be clinically indicated. Most recently, Freyth, Elsesser, Lohrmann, and Sartory (2010) conducted a study assessing the effects of treatment for ASD on psychological as well as physiological outcome measures such as heart rate and skin conductance. Forty recent trauma survivors were assigned to three sessions of either PE (n = 19) or SC (n = 21), with both groups also receiving psychoeducation and progressive relaxation. The PE and SC treatment components were conducted in similar fashion to other ASD treatment studies (e.g., Bryant et al., 1999), but were shorter in duration (three versus five sessions). Additionally, although participants in the PE group were asked to carry out relaxation exercises at home, there was no specific assignment for trauma exposure based homework. In contrast to Bryant et al., results from the study by Freyth et al. (2010) revealed no significant main effects between the PE and SC treatment conditions on posttraumatic symptoms, posttraumatic cognitions, dissociation, state or

trait anxiety, or depression at posttreatment or 3-month follow-up. A unique aspect of this ASD study was the measurement of physiological responses to traumarelated and neutral stimuli. The PE group did demonstrate greater attenuation in heart rate response to trauma-related stimuli at posttreatment and 3-month follow-up compared to the SC group. Several limitations are important to consider when discussing results of this study. Although the majority of subjects met diagnostic criteria for ASD at pretreatment (n = 24), the remaining participants (n = 13) met criteria for subthreshold ASD by endorsing less than three dissociative symptoms. Researchers did not specify whether these subjects were distributed evenly between treatment conditions. Researchers also reported the number of participants meeting full or subclinical PTSD at follow-up, which is difficult to compare with other studies that listed assessment for the full criteria of PTSD. The failure to find differences between the PE and SC treatment conditions could have been affected by the inclusion of subclinical ASD participants in the treatment sample, differences in the application of PE, as well as shorter treatment duration compared to prior studies. After discussing the specific results from each ASD treatment outcome study, some more general observations and conclusions can be drawn. Dropout from trauma-focused treatment in general is a concern, but may take on additional importance when trying to engage individuals with ASD in treatment shortly after their traumatic event. Therefore, information provided in the nine ASD treatment outcome studies was reviewed to determine any trends in causation for dropout. Two studies reported that no participants dropped out during the course of the study (Bryant et al., 1998; Bryant, Moulds, Guthrie, & Nixon, 2003). Four other studies reported that analyses comparing treatment completer to dropout participant characteristics revealed no significant differences (Bryant et al., 2008, 2006; Bryant, Moulds, & Nixon, 2003; Freyth et al., 2010). In studies that identified differences between treatment completers and dropouts, it was reported that subjects dropping out from treatment had higher trauma-related symptoms and state anxiety scores (Bryant et al., 1999; Bryant, Moulds, & Nixon, 2003) and had less confidence in treatment (Bryant et al., 2005). Results were mixed based on whether type of treatment lead to higher dropout rates (Bryant et al., 2005; Nixon, 2007). Continuing to analyze whether specific components of the treatment or specific characteristics of participants are more strongly associated with dropout can inform how to make treatment adjustments and maximize client retention. Elapsed time since the trauma is also a significant variable to consider related to symptoms and treatment of trauma-exposed individuals. Diagnosis of ASD must occur

ASD Treatment Outcomes within the first month following exposure to a traumatic event and initiating ASD treatment within this time frame is indicated. Studies included in this review often stated that initial assessments occurred within 2 weeks to 1 month of exposure to the traumatic event. The time frame of treatments was also specified including a range of three to six sessions provided on a weekly basis. However, authors commonly failed to provide other information related to time that could affect study results, including length of time that had elapsed from trauma exposure to the first treatment session and from trauma exposure to completion of treatment. The study completed by Bryant et al. (1998) was a noted exception as it listed the mean time between pretreatment and posttreatment assessment. Due to the relevance of time based on the diagnostic criteria of ASD and the literature discussing the remission of trauma-related symptoms over time, more explicit reporting of the average time between trauma exposure and pretreatment assessment, onset of treatment, and conclusion of treatment would be useful in evaluating ASD treatment study results. Finally, dissociative symptoms are a key feature in the diagnosis and clinical presentation of ASD. Therefore, it should logically follow that assessment of dissociative symptoms at the pretreatment assessment, over the course of treatment, and at follow-up assessments would be a meaningful gauge of treatment effectiveness. However, only two studies administered any questionnaire meant to specifically assess dissociative symptoms (Bryant et al., 1998; Freyth et al., 2010) and assessment in these studies was completed exclusively at the pretreatment assessment. Future treatment studies and clinical practice with clients suffering from ASD could benefit from regular assessment of dissociative symptoms, which are so central to the experience of this disorder (See Table 1 for description of studies). Clinical Dilemmas Related to ASD Clinicians have several important decisions to make when working with clients in the first month following exposure to a traumatic event. By implementing a thorough initial assessment, clinicians must differentiate normative posttraumatic responses from pathological responses in need of clinical intervention as indicated by the criteria for ASD. If a client is exhibiting clinically significant signs of distress in the first 2 weeks following exposure to a trauma, it is recommended that psychological first aid be applied that focuses on “fostering safety, calmness, self- and community efficacy, social connectedness and optimism” (Benedek, Friedman, Zatzick, & Ursano, 2009). This approach serves to strengthen the individual's internal and social coping resources and promote natural recovery. If the individual continues to

experience significant distress past the 2-week mark, more directive ASD treatments are recommended with the aim of resolving immediate symptoms as well as preventing the onset of PTSD. An important gap in the clinical literature regarding the treatment of trauma-exposed individuals is how to assist clients that meet criteria for ASD in the first month following a trauma and continue to experience some distress past the 1-month mark, but do not meet criteria for PTSD. In this case, the clinician is limited in the diagnostic options (e.g., adjustment disorder, anxiety disorder NOS) that are available to appropriately label the client's experience. Additionally, ambiguity exists as to the best course of treatment in this circumstance. If the client appeared to be responding well to ASD treatment indicated by a reduction in symptoms, then continuation of this treatment past the 1-month mark seems warranted. Initiating one of the established treatments for PTSD is also an option. Generally speaking, clinical wisdom guided by the empirical literature reviewed here must be used to implement treatment that best addresses the client's symptom picture, irrespective of the time frame in which they are occurring.

Conclusions and Future Directions Since its inception in DSM-IV, the role of ASD and the diagnostic criteria that define it have been a point of controversy. Specifically, people have questioned whether ASD defines a clinical disorder in a way that is distinct from PTSD and whether the current diagnostic criteria (particularly the dissociative symptoms) accurately define the symptoms suggestive of pathological distress in the first month following trauma. However, the present review of the ASD literature concludes that the ASD diagnosis serves the function of identifying clients exhibiting high levels of distress that are in need of more immediate treatment as well as being at increased risk for developing more chronic forms of psychopathology. In light of the clinical impact caused by the symptoms of ASD, the development and implementation of treatments aimed toward resolving these symptoms is imperative. Utilizing this review as a backdrop for informing treatment decisions, clinicians may draw several conclusions regarding how best to assist their clients. Consistent with the larger trauma treatment literature, rates of attrition and longevity of treatment gains have been identified as potential obstacles to successful treatment for ASD, and more attention is being placed on these factors to address their effects. However, the overarching conclusion based on the ASD treatment outcome literature is that cognitive behavioral treatments have repeatedly demonstrated efficacy in resolving the symptoms of ASD. Specifically, treatments including the CBT components of psychoeducation, imaginal exposure, in-vivo exposure, cognitive

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Table 1

Treatment Outcome Studies for ASD Year

Trauma Type

Sample

Pretreatment Diagnosis

Intervention

Measures

Follow-up Duration

Bryant, Harvey, Dang, Sackville, & Basten

1998 MVA or industrial group accident

Bryant, Sackville, Dang, Moulds & Guthrie

1999 MVA or non-sexual N = 45 assault

Bryant, Moulds, Guthrie, & Nixon

2003 MVA or non-sexual N = 24 assault

Bryant, Moulds & Nixon

2003 MVA or non-sexual N = 41 assault

Bryant, Moulds Guthrie & Nixon

2005 MVA or non-sexual N = 69 assault

Outcome

N = 24

ASD

CBT vs. SC (5 90 min. sessions)

ASDI, IES, BDI, STAI, CIDI, DES

ASD, Subthreshold ASD (2 of 3 dissociative symptoms; 7 subjects) ASD

PE, PE + anxiety management, SC (5 90 min. sessions)

ASDI, IES, BDI, STAI, CAPS

6 months 17% of CBT compared to 67% of SC met for PTSD. CBT group reported less intrusion, avoidance, and state anxiety at posttreatment and follow-up as well as less depression at follow-up. 6 months 14% PE, 20% PE + anxiety management, 56% of SC group met for PTSD. SC group had significantly higher symptoms PTSD compared to PE and PE + anxiety management.

CBT, SC (5 90 min. sessions)

ASDI, IES, BDI, CAPS

ASD

CBT, SC (5 90 min. sessions)

ASDI, IES, BDI, STAI, CIDI/CAPS

ASD

CBT, CBT + hypnosis, SC (5 90 min. sessions)

ASDI, IES, BDI, BAI, CAPS, Stanford Hypnotic Clinical Scale

6 months 17% of CBT, 58% of SC group met for PTSD. CBT group had significantly larger reductions in PTSD symptoms at posttreatment and follow-up and less anxiety at posttreatment. 4 years 8% of CBT, 25% of SC group met for PTSD. CBT group reported significantly lower frequency and intensity ratings for PTSD avoidance symptoms and lower total PTSD intensity scores. 6 months 59% of SC, 21% of CBT, and 22% of CBT + Hypnosis group met for PTSD. CBT and CBT + Hypnosis groups reported less PTSD symptoms compared to SC group at posttreatment and follow-up.

Koucky et al.

Author

Bryant, Moulds, 2006 MVA or non-sexual N = 53 Nixon, assault Mastrodomenico, Flemingham & Hopwood

ASD

Nixon

2007 Physical or sexual assault

N = 20

ASD

Bryant et al.

2008 MVA or non-sexual N = 90 assault

ASD

Freyth, Elsesser, Lohrmann & Sartory

2010 Accident, physical or sexual assault

ASD or subclinical ASD

N = 40

CBT, CBT + Hypnosis, SC (5 90 min. sessions)

ASDI, IES, BDI, BAI, CAPS, Stanford Hypnotic Clinical Scale

3 years

Note. MVA= motor vehicle accident, PTSD= posttraumatic stress disorder, ASD= acute stress disorder, CBT= cognitive behavioral therapy, SC= supportive counseling, PE= prolonged exposure, CPT= cognitive processing therapy, CR= cognitive restructuring, ASDI= Acute Stress Disorder Interview, ASDS =Acute Stress Disorder Scale, BAI= Beck Anxiety Inventory, BDI= Beck Depression Inventory, CAPS-2= Clinician Administered PTSD Scale, CIDI= Composite International Diagnostic Interview, DES= Dissociative Experiences Scale, DIPS= Diagnostisches Interview bei Psychische (the German version of the ADIS-IV), DQ= Dissociation Questionnaire, IES= Impact of Event Scale, PDS= Posttraumatic Distress Scale, PTCI= Post-traumatic Cognitions Inventory, SCID= Structured Clinical Interview for DSM Disorders, STAI= State-Trait Anxiety Inventory.

ASD Treatment Outcomes

10% of CBT, 22% of CBT + Hypnosis, 63% of SC group met criteria for for PTSD. CBT and CBT + Hypnosis reported significantly less re-experiencing and avoidance symptoms compared to the SC group. CPT, SC ASDI, SCID, CAPS, None 13% of CPT, 40% of SC met criteria for (6 90 min. sessions) ASDS, PDS, BDI-II, PTSD. No significant difference in PTCI, Acceptability/ continuous measures of PTSD Credibility symptoms, depression, or questionnaire trauma-related beliefs between groups. PE, CR, or ASDI, CAPS, SCID, 6 months 37% of PE, 63% of CR group met Waitlist (5 90 min. BDI, BAI, IES, PTCI, criteria for PTSD. PE group reported sessions) Credibility/Expectancy significantly less PTSD symptoms Questionnaire compared to CR at follow-up. PE or SC, ASDI, DIPS, IES-R, 3 months 38% of SC and 28% of PE met for psycho-education, DQ, PTCI, STAI, BDI, full or sub-clinical PTSD. No progressive muscle psychophysio-logical significant difference relaxation (1 90 min., measures between PE and SC group on 2 60 min.) posttraumatic symptoms, cognitions, anxiety, or depression. Greater attenuation in heart rate for PE group.

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Koucky et al. restructuring, and progressive muscle relaxation have demonstrated success based on the current literature. Clinicians must continue to search for ways to tailor and optimize CBT for ASD. This review of the ASD literature also identified several areas that require further resolution and should continue to be investigated in future research and applied in clinical practice. Dissociative symptoms are the hallmark component of the ASD diagnostic criteria that distinguishes it from other disorders. Some ambiguity exists regarding the most accurate way to assess the onset and intensity of dissociative symptoms to differentiate between normative and pathological levels of distress. Currently, the diagnostic criteria do not specify whether dissociative symptoms must occur during the trauma or sometime afterward, but the temporal relationship of dissociative symptoms to the traumatic event is meaningful. Specifically, data suggest that persistent dissociation is a more relevant factor in identifying individuals who later develop PTSD (Briere et al., 2005). Persistent dissociation has also been shown to negatively impact the course of treatment for some disorders (Rufer et al., 2006; Spitzer, Barnow, Freyberger, & Grabe, 2007) and decreases in persistent dissociation were positively associated with changes in PTSD symptoms (Lynch, Forman, Mendelsohn, & Herman, 2008). Due to this evidence pointing to the impact of dissociation on initial severity of posttraumatic symptoms and course of treatment, more specificity regarding the definition and assessment of dissociative symptoms and monitoring of dissociative symptoms throughout ASD treatment should occur. As noted throughout the review, the diagnosis of ASD requires the presence of dissociation. However, there is little available information on specific interventions designed to directly target these symptoms in clinical care. The incorporation of therapeutic grounding techniques designed to specifically reduce dissociation may be helpful in this regard. Such grounding techniques can include walking during the therapy session, tactile exercises with objects such as rolling a ball between one's fingers, and setting a timer during session or practice work to reorient the client. The goal of these techniques is to disrupt dissociative symptoms and keep the client engaged in traumafocused work enough to experience symptom change. Engaging and retaining individuals in trauma-focused treatment can include significant challenges. Avoidance is a large part of this disorder and the available therapies require a participant to break through this avoidance, which can be very difficult but is essential to change. A recent review of PTSD treatment studies completed by Schottenbauer, Glass, Arnkoff, Tendick, and Gray (2008) listed dropout rates as high as 50% for some studies. Consistent with the larger trauma literature, the preceding review of ASD treatment studies also identified participant retention as an issue. Clinicians treating clients with ASD

should be aware of the risk for treatment dropout generally associated with trauma-focused treatment, but research is mixed on whether specific characteristics or types of treatment are more likely to yield client dropout. Motivational interviewing (MI) techniques have been utilized in parallel trauma populations to increase engagement in therapy and facilitate therapy completion (Murphy, Thompson, Murray, Rainey, & Uddo, 2009). Although not specifically tested within the trials reviewed here, a wealth of data on MI suggest that this therapeutic strategy as an excellent option to increase motivation to change. Due to the high prevalence of trauma exposure in those that may present for treatment, clinicians can benefit from being attuned to the issues presented in this review related to ASD. Specifically, clinicians should regularly assess for ASD when clients present for treatment soon after exposure to trauma. Additionally, clinicians should be familiar with the CBT treatment approaches that have been identified as effective at resolving this distress. The conceptual picture and clinical function of ASD will continue to be refined based on revisions projected in DSM-5 that deemphasize the role of dissociative symptoms. In the meantime, clinicians and researchers can move forward utilizing the solid foundation of studies demonstrating the treatment efficacy of CBTs in ameliorating the symptoms of ASD.

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Received: July 10, 2010 Accepted: July 1, 2011 Available online 29 July 2011